Dead-donor’ rule dangerously misleading, experts say

Dr. Fraser Rubens works alongside nurse Elizabeth Knapp as he pours litres of warmed-up saline solution into the chest cavity after a new heart has been placed in Jack Quinte. Copyright: Julie Oliver / Postmedia News files.

"Doctors should abandon the 'dangerously misleading' policy of having to declare donors dead before their organs can be extracted for transplant, and adopt a more honest policy that acknowledges some patients may still be technically alive, Canadian and Spanish experts suggest in a provocative new commentary.
They advocate replacing the current 'dead-donor rule' with a policy that educates the public about the true nature of patients used in transplant, obtains informed consent — and ensures the donor does not suffer during the organ harvesting.

The authors, including Dr. Neil Lazar, director of the medical-surgical intensive care unit at Toronto General Hospital, say the focus should be on the well-being of donors rather than whether they are legally dead. That could mean giving anesthetics during organ harvesting.

'Because there is a general assumption that dead individuals cannot be harmed, veneration of the dead-donor rule is dangerously misleading,' they wrote. 'Ultimately, what is important for the protection and respect of potential donors is not to have a death certificate signed, but rather to be certain they are beyond suffering and to guarantee that their autonomy is respected.'
The suggestions, made at a major U.S. bioethics conference last week and in a recent paper in the American Journal of Bioethics, are coming under strenuous criticism by the transplant community, however. Some experts call the proposal a theoretical argument that has little foundation in reality, but that could seriously hurt the ongoing struggle to recruit potential organ donors.
'In the overwhelming majority of cases, the concept of death is easy, obvious and not really subject to any complex interpretation. It’s very clear,' said Dr. Andrew Baker, medical director of the Trillium Gift of Life Network, which oversees Ontario’s transplant system. 'They’re dead, you can see it, there is no return of anything.'
Dr. Baker, head of trauma and neurosurgery at Toronto’s St. Michael’s Hosptial, said he sees daily the medical 'marvel' of organ transplantation, the lives it saves and the consolation it gives to the relatives of dead patients. It would be tragic if donation rates were undermined by unfounded concerns, he said.
'If you said ‘No’ [to donation] for the totally wrong reason, because the National Post wrote that some good doctor said you might feel something [during organ harvesting], that would just be too much.'
Dr. Sam Shemi, a prominent Montreal intensive-care physician, echoed his concerns. Determining death in organ donation cases 'is more professional, rigorous and performed according to a higher standard than in any other situation,' he said.
In questioning death declaration, the bioethics paper focuses largely on a recent trend in transplantation.
Most transplant organs are taken from patients declared brain dead. Those people account for only about 10% of hospital deaths, however, leaving a shortage of donors and hundreds of gravely ill Canadians languishing and dying on transplant waiting lists.
In response, the medical community has recently embraced a new protocol, where organs are removed after the heart has stopped — in Canada, five minutes after it has halted — but when the patient is not necessarily brain dead. Approved at a 2006 conference of experts, the procedure has been used hundreds of times since across the country, helping increase the total number of donors by more than 25% in Ontario alone.
While the medical community generally supports 'donation after cardiac death [DCD],' there has been some controversy. The paper by Dr. Lazar and colleagues notes that in most DCD cases, doctors have made a decision not to continue life-support measures that keep the patient breathing and their heart beating. That does not necessarily mean the heart could not be started again, artificially at least, they argue.
It is also possible that when cardiac death is declared, there may still be some brain activity, raising at least the possibility the donor could feel pain during the harvesting of organs, the paper argues. The process of inserting catheters that pump blood through the transplant organs before removal could also start blood circulation in the brain, triggering some limited activity there, the article says.
Dr. Baker said there is no evidence, however, that cardiac death is anything but the complete lack of life. When someone is removed from a ventilator, first they stop breathing, then their heart stops. That means that the brain stem, which regulates those activities and is considered the last part of the brain to die, would have lost all function.
And perfusion is done here in a way that there is no blood flow through the brain, he said.
James DuBois, a health ethics professor at Saint Louis University, also argued that determination of death is well-founded in transplant cases, and worried about the impact of removing the dead-donor rule.
It could 'have negative consequences: decreasing organ donation rates, upsetting donor family members and creating distress among health care workers,' he wrote in a response published by the bioethics journal."

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In March 2005, I've initiated a blog about bioethics. Organ replacement technologies and genomics are part of today's sustainable health economics. This is not medicine under ideological pressure ! ...